management of acute decompensated heart failure of hf_c… · 2012 trinity health - novi, michigan...

Management of Heart Failure Across the Continuum

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Objectives:At the end of this course, you will be able to:

2012 Trinity Health - Novi, Michigan - INTERNAL

1. Describe the different types of Heart Failure (Systolic versus Diastolic )

2. Describe both, the ACC stages and NYHA classes of Heart Failure

3. Identify recommended therapies for treatment of Heart Failure

4. Explain the different medication classes and their uses for the treatment of Heart Failure

5. Identify differences between ambulatory, inpatient and transitional Heart Failure patient treatment goals

6. Explain the differences between ambulatory, inpatient and transitional monitoring

7. Describe potential causes for readmission of a heart failure patient

Heart Failure Across the Continuum – Table of Contents1. What is Heart Failure

Types of Heart FailureSystolic vs. DiastolicACC StagesNYHA ClassesVentricular RemodelingPathophysiology

4 – 13

2. HF in Ambulatory CareHistory and PhysicalRecommended Therapies: Considering ACC StageMedications overview

• ACE / ARB / B-Blocker• Diuretics• Others

Transition to inpatient care

14 – 20

21 – 32

3. Hospitalized Patient (Inpatient Care)Goals of ED and IP Care Treatment / acute presentationClinical features / causes of acute clinical changeSpecial concerns and Key tests (BNP, ECHO, ECG, CXR)Principles of treatment Indications for Invasive TherapyDocumentation for improved codingTransition to ambulatory care

33 – 54

4. Transitional CareTransition support Causes of readmission for HFRemote Monitoring and Readmission Risk AssessmentPalliative Care

55 – 59

5. Conclusions 60

6. Appendix and References 61 – 70

Post test with answers 71 – 72


• A clinical syndrome resulting from any structural or functional cardiac defect limiting ventricular filling, a syndrome is described by specific symptoms and signs

• Around 5.8 million people in the United States have heart failure. • About one in five people who have heart failure die within one year from diagnosis.• HF ranks as the most frequent cause of hospitalization and re-hospitalization

among older Americans.1,2

• In 2010, heart failure will cost the United States $39.2 billion.3 This total includes the cost of health care services, medications, and lost productivity.

• The most common causes of heart failure are coronary artery disease, high blood pressure, and diabetes.

• HF is diagnosed on the presence of characteristic signs and symptoms and not on the basis of any diagnostic tests

– Tests such as echocardiograms and cardiac stress testing establish thepathophysiologic cause but do not define whether heart failure is present or not

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What is Heart Failure?


1 Wier LM, Levit K, Stranges E, et al. HCUP Facts and Figures: statistics on hospital-based care in the United States, 2008: exhibit 2.3, most frequent principal diagnoses by age. Agency for Healthcare Research and Quality. http://www.hcup-us.ahrq.gov/reports.jsp. 2 Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009;360(14):1418-1428. 3 Lloyd-Jones D, Adams RJ, Brown TM, et al. Heart Disease and Stroke Statistics—2010 Update. A Report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee . Circulation. 2010;121:e1-e170.

http://circ.ahajournals.org/cgi/reprint/CIRCULATIONAHA.108.191261v1



Types of Heart Failure

• There are several ways to clinically classify heart failure: – By type

• Systolic versus diastolic– By stages or classes

• American College of Cardiology (ACC)/American Heart Association (AHA), Stages A, B, C and D

• New York Heart Association classes I - IV– By underlying cause

• Ischemic, due to radiation therapy, etc.– By anatomical location

• Right versus left

• Coding classifications and definitions focus primarily on systolic versus diastolic (or both) and acute versus chronic (or both). Specific documentation is necessary to help coding accurately reflect severity of illness and risk of mortality


Systolic Versus Diastolic Heart Failure

• In 1994, the Agency for Healthcare Research and Quality (AHRQ) in association with the American Heart Association and the American College of Cardiology, developed guidelines to distinguish systolic and diastolic dysfunction.

• It is important to distinguish between the two as their long-term treatments are different.

• Patients may also have combined systolic and diastolic heart failure.


• Systolic heart failure is characterized by inability of heart muscle to contract vigorously – Results in inadequate amount of blood

and oxygen to body– Failure to contract adequately causes

fluid backup into the lungs causing pulmonary congestion

• Evidenced by:– Ejection Fraction usually less than

40%– Confusion – Shortness of breath – Diaphoresis – Fatigue– Pulmonary edema

• Common patient populations include:– Men aged 50-70; patients with CAD,

Hx MI, or certain cardiomyopathies

• Diastolic heart failure occurs when the heart has a problem relaxing between contractions (diastole) to allow enough blood to enter the ventricles.

– Results in systemic fluid accumulation– Some patients may also have pulmonary

congestion • Evidenced by:– Ejection fraction >50%– Jugular vein distension (JVD)– Peripheral edema (especially in legs,

ankles and feet)– Ascites/Anasarca– Hepatomegaly– Pulmonary Hypertension• Common populations include:– Older women; patients with obesity,

hypertension and chronic lung conditions


Systolic Versus Diastolic Heart Failure (continued)

ACC/AHA Stages for Heart Failure (cont.)


At Risk for Heart Failure:STAGE A High risk for developing HF

STAGE B Asymptomatic LV dysfunction

• Designed to emphasize preventability of HF

Heart Failure:STAGE C Past or current symptoms of HF

STAGE D End-stage HF

• Designed to recognize the progressive nature of LV dysfunction

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ACC/AHA Stages for Heart Failure (cont.)


Complement, but do not replace NYHA classes

• NYHA Classes - shift back/forth in individual patient (in response to Rx and/or progression of disease)

• ACC Stages - progress in one direction due to cardiac remodeling

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NYHA Classes for Heart Failure

2012 Trinity Health - Novi, Michigan - INTERNAL 10

Patients with:─Previous MI─LV remodeling including LVH and Low EF─Asymptomatic valvular disease

ACC/AHA Stages for Heart Failure


Stage AAt high risk for HF

but without structural

heart disease or symptoms of HF

Stage BStructural heart disease but without

symptoms of HF

Stage CStructural heart disease with

prior or current symptoms of HF

Stage DRefractory HF requiring specialized interventions

Patients with:─Hypertension─Atherosclerosisdisease

─Diabetes─Metabolic syndrome

Or

Patients─Using cardiotoxins─With HFx CM

Patients with:Known structural heart disease

And

Shortness of breath and fatigue, reduced exercise tolerance

Patients:Who have marked symptoms at rest despite maximal medical therapy (e.g. those who are recurrently hospitalized or cannot be safely discharged from the hospital without specialized interventions

At Risk for Heart Failure Heart Failure

Ventricular Remodeling - Illustration


Ventricular remodeling ‐ Cross‐sectional view of left and right ventricles:a, normal; b, concentric hypertrophy; and c, eccentric hypertrophy.Abbreviations: LV, left ventricle; RV, right ventricle. Produced and printed with permission from The Cleveland Clinic Foundation; Cleveland, Ohio.

a b c

RV LV RV LV RVLV

Source: CRITICALCARENURSE Vol 24, No. 6, DECEMBER 2004 , pg 18

Consequences of Ventricular Remodeling:High Pressure (wall stress) heightens myocardial oxygen consumption, which promotes further hypertrophy and activatesneurohormonal systems –resulting in reduction of ejection fraction, ventricular performance, morbidity and mortality.

Goals for Understanding Ventricular Remodeling: Promote regression and prevent progression of LV enlargement to decrease disease progression and improve survival

↑ MVO2

↑Heart Rate

↑Ischemia

↑Wall stress

Afterload mismatch↓Cardiac

output ↓ LV contractility ↑Vasoconstriction InflammatoryNeurohormonal

activation

Hypoperfusion/Hypotension

↑Wall stress↑Diastolic

dysfunction Volumeredistribution

End organdysfunction

Inflammatory/Neurohormonal

activation

↑Left atrial andPulmonary

Venous pressure

Alveolar-Capillary leak

Renal dysfunction(fluid and salt retention)

Blood volumeexpansion

Pulmonaryedema

Hypoxia

Pathophysiology of Acute HF


AMBULATORY CAREHeart Failure in


Heart Failure in Ambulatory CarePatient History & Physical for identification of potential HF


Presenting Symptoms

Past Medical History

Family, Social and Dietary History

Physical Exam

• Cough/sputum production

• Dyspnea on exertion• Paroxysmal nocturnal

dyspnea• Orthopnea• Chest pain• Palpitations• Edema• Fever or viral illness• Fatigue• Recent weight gain• Decrease exercise

intolerance• Blood loss

• History of HF• History of MI• Cardiac risk factors• HTN/smoking/DM/^lip

ids• RF/Endocarditis• Thyroid dysfunction• Thromboembolic

disease• Postpartum• Blunt chest trauma• HIV

• Ischemic heart disease• HF• Congenital heart

disease• Risk factors for ASCAD• Salt and fluid intake• Tobacco use / abuse• Alcohol use / abuse• Drug abuse• Other Toxins

(Chemotherapy, Stimulants, TCA, COX-1 and COX-2 inhibitors,Glitazones,glucocorticoids)

• Vital signs (including height and weight)

• Cyanosis, pallor, jaundice• Diaphoresis• Labored breathing, rales >

25%, lung sound that do not clear with cough

• Tachycardia, bradycardia, arrhythmias

• Left lateral displacement of point of maximal impulse

• S3, S4, or murmur• Elevated jugular venous

pressure, + hepato-jugular reflux

• ABD, large, pulseatile, or tender liver

• Decreased peripheral pulses• LE edema

Heart Failure in Ambulatory CareRecommended Therapies; Reduce Risk: Patients in Stage A

• Treating known risk factors (hypertension, diabetes, etc.) with therapy consistent with contemporary guidelines

• Avoiding behaviors increasing risk (i.e., smoking, excessive consumption of alcohol, illicit drug use)

• Periodic evaluation for signs and symptoms of HF

• Ventricular rate control or sinus rhythm restoration

• Noninvasive evaluation of LV function

• Drug therapy– Angiotensin Converting Enzyme Inhibitors (ACEI)– Angiotensin Receptor Blockers (ARBs)


Heart Failure in Ambulatory CareRecommended Therapies: Patients in Stage B

• General Measures as advised for Stage A

• Drug therapy for all patients– ACEI or ARBs– Beta-Blockers

• ICDs in appropriate patients

• Coronary revascularization in appropriate patients

• Valve replacement or repair in appropriate patients


Heart Failure in Ambulatory CarePatients in Stage C with Reduced LVEF with Symptoms

• General measures as advised for Stages A and B• Drug therapy for all patients

– Diuretics to reduce fluid retention– ACEi– Beta-blockers (reduces mortality)– Avoid NSAIDS, most anti-arrhythmics and most Ca2+ channel blockers

• Drug therapy for selected patients– Aldosterone Antagonists (moderately severe symptoms, and easy to monitor)– ARBs (for those ACEi intolerant)– Digitalis (reduces hospitalizations)– Hydralazine/nitrates (ACEi / ARB intolerance; hypotension or renal

insufficiency• ICDs in appropriate patients (primary prevention of SCD and secondary

prevention prolong survival)• Cardiac resynchronization in appropriate patients• Exercise Testing and Training


Heart Failure in Ambulatory CarePatients in Stage C with Normal LVEF with Symptoms

• Treating known risk factor (hypertension) with therapy consistent with contemporary guidelines

• Ventricular rate and sinus rhythm control for all patients• Restoration/maintenance of sinus rhythm in appropriate patients• Drugs for all patients

– Diuretics (control pulmonary congestion and peripheral edema)• Drugs for appropriate patients

– ACEI– ARBs– Beta-Blockers

• Coronary revascularization in patients with CAD in whom symptomatic or demonstrable myocardial ischemia is judged to be having an adverse effect on cardiac function


Might be effective in symptom control, with controlled hypertension

• Patients are now symptomatic at rest despite optimal medical therapy – requiring close monitoring:– Close management of fluid retention and other symptoms– Refer for transplant if potentially eligible– Refer to a HF program with expertise in refractory HF– Discuss End of Life care

• May include AICD deactivation

• For selected patients consider the following:– LVAD (Left Ventricular Assist Device)– PA (Pulmonary Artery) catheter placement – Continuous IV infusion of a positive inotrope (palliation)

Heart Failure in Ambulatory CarePatients in Stage D (Refractory Heart Failure)


MEDICATIONSHeart Failure


Heart Failure in Ambulatory CareMedication Overview:

• ACEi if– Current/prior symptoms of HF– Reduced LVEF

• ARB’s• Β-Blockers• Diuretics and Salt

Restriction if– Current/prior sx of HF– Reduced LVEF– Fluid Retention

• Aldosterone Antagonists• Hydralazine and long

acting nitrites• Digoxin

• Rx to avoid– NSAIDs– Most anti-arrhythmics– Most Ca2+ channel blockers


ACE Inhibitors

Selection Exclusions Monitoring•SBP> 85 mmHg•Minimal volume overload

•Dose increased at intervals determined by BP and renal function

•Patients with borderline renal titration should be slower

•ACE allergy•Moderate severe AS•Cardiogenic shock•BP <80 mmHg•Hyperkalemia•Serum Creatinine>3•Bilateral Renal arterystenosis

•Pregnancy•Any in patient requiring IV pressors

•Cough• Increase fatigue•Dizziness•SBP <80•Renal function•Lowest diuretic possible

•Stagger ACE and B-Blockers

•Avoid NSAID’s


ACE Agents

Agent Initiation Steps Target

Captopril 6.25mg tid 12.5-25mg tid 50mg tidEnalapril 2.5mg bid 5mg bid 2.5-20mg bidLisinopril 5mg daily 5, 10mg daily 5-40mg dailyRamipril 2.5mg bid 2.5mg bid 5mg bidQuinapril 5mg bid 10mg bid 10-20mg bidFosinopril 10 mg daily 5-10-20mg daily 20-40mg daily

ACC Guidelines:•ACEIs and Beta-blockers should be used in all patients with a recent or remote history of MI regardless of EF or presence of HF. •ACEI should be used in patients with a reduced EF and no symptoms of HF, even if they have not experienced MI. •ACEI or ARBs can be beneficial in patients with hypertension and LVH and no symptoms of HF.


ARB’s

Selection Exclusions Monitoring•May be used if ACE’scannot be tolerated

•SBP > 85 mmHG•Minimal fluid overload•Dose increase determined by BP and renal function

•Patients with border line renal function should betitrated slower

•Only Valsartan andCandesartan are approved for use in patients with HF

•Allergy•Cardiogenic shock•Hypoperfusion•SBP<80 mmHg•Pregnancy•Any patient on IVpressors

•Severe renal arterystenosis

•Potassium > 5.5

• Increase fatigue•Dizziness•SBP < 80 mmHg•Renal function•Not be used with ACE and B-Blocker

•Avoid NSAID’s


ARB Agents

Agent Initiation Titration Target

Candesartan 4mg daily 8-16-32mg daily

32mg daily

Losartan 25mg daily 50-100mg daily 100mg daily

Valsartan 40mg bid 80mg bid 160mg bid

ACC Guideline:• For older patients – “start low and go slow”•An ARB should be administered to post-MI patients without HF who are intolerant of ACEIs and have a low LVEF.•ACEIs or ARBs can be beneficial in patients with hypertension and LVH and no symptoms of HF.•ARBs can be beneficial in patients with low EF and no symptoms of HF who are intolerant of ACEIs.


B-Blockers

Selection Exclusions Monitoring•SBP >85 mmHg•Not requiring IVpressors

•No longer significantly volume overload

•Used with ACE inhibitors

•When only one drug can be initiated for HF, B-Blockers are preferred

•Cardiogenic shock•Hypoperfusion•SBP<80 mmHG•Symptomaticbradycardia

•Significant volume overload

•Hold if SBP<80 mmHg•Hold HR < 55 bpm•Monitor daily weights•May cause increase fatigue, weight gain, dizziness, and or heart block

•Prescribe lowest diuretic possible

•Stagger B-blocker and ACE dosing

•Avoid NSAID’s•An ARB should NOT be given with ACE and B-blocker


B-Blockers Agents


Carvedilol 3.125mg bid 6.25-12.5mg bid 6.25-25mg bid

Metoprolol 6.25-25mg QD 25, 50 100mg daily 200 mg dailyBisoprolol 1.25mg daily 2.5-5mg daily 10mg daily

Titration Recommendations:• Start while in hospital and D/C on that dose if tolerating• Increase at 2-4 week intervals until target dose is reached or patient becomes

symptomatic

ACC Guidelines:• Beta-blockers and ACEIs should be used in all patients with a recent or remote history of MI regardless of EF or presence of HF.

• Beta-blockers are indicated in all patients without a history of MI who have a reduced LVEF with no HF symptoms.

• Beta-blockers (using 1 of the 3 proven to reduce mortality, i.e., bisoprolol, carvedilol, and sustained release metoprolol succinate) are recommended for all stable patients with current or prior symptoms of HF and reduced LVEF, unless contraindicated.


Diuretic Agents


Furosemide 40mg daily 80-160mg daily 160-200mg daily

Bumetanide 1 mg daily 2,4 mg daily 8 mg daily

Torsemide 10mg daily 25,50, 100mg daily 200mg daily

HCTZ 25mg daily 25-50mg daily 50 mg daily

ACC Guidelines:•Diuretics and salt restriction are indicated in patients with current or prior symptoms of HF and reduced LVEF who have evidence of fluidretention.•Monitoring - Smallest dose possible: avoid: hypokalemia;hypomagnesemia; prerenal azotemia; orthostatic hypotension


Aldosterone Antagonists

Agent Initiation TargetSpironolactone 12.5mg daily 25 mg dailyEplerenone 50 mg daily 50 mg daily

ACC Guidelines:• Addition of an aldosterone antagonist is recommended in selected patients with moderately severe to severe symptoms of HF and reduced LVEF who can be carefully monitored for preserved renal function and normal potassium concentration. Creatinine should be less than or equal to 2.5 mg/dL in men or less than or equal to 2.0 mg/dL in women and potassium should be less than 5.0 mEq/L. Under circumstances where monitoring forhyperkalemia or renal dysfunction is not anticipated to be feasible, the risks may outweigh the benefits of aldosterone antagonists.

• Routine combined use of an ACEI, ARB, and aldosterone antagonist is not recommended for patients with current or prior symptoms of HF and reduced LVEF.


Long Acting Nitrates

Agent Initiation Target

Hydralazine 25mg 4 X/d 50mg 4 X /day

Isosorbide dinitrate 30 mg tid 40 mg tid

• Selection– Use with African-Americans who may be

ACE/ARB intolerant, or may not respond to optimal management


Digoxin


TRANSITIONS TO INPATIENTHeart Failure


Heart Failure Care Transitions Ambulatory to Hospital

Goals: Primary Care in the ambulatory setting must coordinate patients returning to the hospital– Ensure patient history and care plan is available for emergency and

or hospital physicians (as necessary or appropriate)– Help patient understand the reasons they will need hospitalization

and what they can do to help avoid these circumstances• Primary care is integral to coordination of patient care; Key concepts: well

coordinated care between providers, across settings and equal coordination of care across providers and settings

• Evidence based care1 means better care for the individual, better health for the population and reduced costs for the health system

• Patient experience should be at the forefront of care– leverage the latest clinical advances and health information technology to ensure

patients receive the most timely, efficient and safest care possible.– latest evidence-based clinical data helps clinicians make the most informed

decisions, when and where they need it.


1 - ACC/AHA Task Force on Practice Guidelines. Manual for ACC/AHA Guideline Writing Committees: Methodologies and Policies from the ACC/AHA Task Force on Practice Guidelines. 2006. Available at: http://www.acc.org/qualityandscience/clinical/manual/pdfs/methodology.pdf and http://circ.ahajournals.org/manual/ . Accessed January 30, 2008.

http://www.acc.org/qualityandscience/clinical/manual/pdfs/methodology.pdf

http://circ.ahajournals.org/manual/

Goals of Emergency / Inpatient Treatment

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• Treat life-threatening conditions• Establish the diagnosis

• Review signs and symptoms• Adequacy of systemic perfusion• Volume status• Get input from PCP or other physicians treating the patient

• Contribution from precipitant or co-morbid factors• Assess and treat any other cardiac and non-cardiac conditions

• Evaluate the Cardiac Status• Evaluate the stage/class; systolic/diastolic• Identify and treat precipitant(s)• Monitor and reassess frequently


Acute Decompensated Heart Failure Presentation

1. Volume overload

Pulmonary and/or systemic congestion frequently precipitated by acute increase in chronic hypertension.

2. Profound depression of cardiac output

Hypotension, renal insufficiency, and/or a shock syndrome.

3. Combination of 1 and 2


Heart Failure - Clinical Features


Cardiac Fluid/Electrolytes Respiratory• Hypotension/Hypertension• Tachycardia (heart rate

>100 bmp)• New arrhythmias or

uncontrolled chronic arrhythmias

• Elevated BNP levels • Ejection fraction may be

impaired or normal depending on type of failure

• Cardiogenic shock

• Weight gain of 2‐3 or more pounds in 1 day

• Jugular vein distention (JVD)

• Edema• Low Sodium and

Chloride levels

• SOB/ Dyspnea/Orthopnea

• Coughing clear, white or pink sputum

• Tachypnea (respirations >24)

• Altered lung sounds: crackles

• Hypoxia/ABG’s with PO2 <70

• Oxygen requirement or need for increasing amounts including BiPap

• CXR noting: “CHF”/Pulmonary edema/Pleural effusion

• Acute respiratory failure

The Hospitalized Patient

Common causes for the acute clinical change:– Non-compliance with Drug therapy or diet– AMI – Acute Myocardial Infarction– Uncorrected high blood pressure– Atrial fibrillation or other arrhythmia– Recent addition of negative inotropic drugs (verapamil, nifedipine,

diltiazem, beta blockers)– Pulmonary Embolism– NSAID, EtOH, or illicit drug use– Endocrine abnormalities (Diabetes, thyroid disease)– Concurrent infection (Pneumonia, viral illnesses)


The Hospitalized Patient

• Special concerns during the H&P– Establish the diagnosis (symptoms and signs of HF)

• Class/Stage– Adequacy of systemic perfusion– Volume status– Contribution from precipitant or co-morbid factors

• Key tests:– Electrocardiogram (ECG)– Chest radiography (CXR)– B-type natriuretic peptide; N-terminal pro b-type natriuretic– Echocardiography


Electrocardiogram: Common Abnormalities in Heart Failure

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Abnormality Causes Clinical implications

Sinus tachycardia Decompensated HF; anemia; fever; hyperthyroidism Clinical assessment; Laboratory investigation

Sinus bradycardia b-Blockade; Digoxin; Anti-arrhythmics; Hypothyroidism; Sick sinus syndrome Evaluate drug therapy; Laboratory investigation

Atrial tachycardia/flutter/fibrillation

Hyperthyroidism; infection; mitral valve diseases;Decompensated HF; myocardial infarction

Slow AV conduction; medical conversion;electroversion; catheter ablation; anticoagulation

Ventricular arrhythmias Ischemia; infarction; cardiomyopathy; myocarditis;hypokalemia, hypomagnesaemia; Digitalis overdose

Laboratory investigation; Exercise test; perfusion studies; coronary angiography,electrophysiology testing; ICD

Ischemia/Infarction Coronary artery disease Echo; troponins; coronary angiography;revascularization

Q waves Infarction; hypertrophic cardiomyopathy; LBBB, pre-excitation Echo; coronary angiography

LV hypertrophy Hypertension; aortic valve disease; hypertrophic cardiomyopathy Echo/Doppler

AV block Infarction; drug toxicity; myocarditis; sarcoidosis;Lyme disease

Evaluate drug therapy; pacemaker; systemic disease

Microvoltage Obesity; emphysema; pericardial effusion;amyloidosis Echo; chest X-ray

QRS length > 120 ms of LBBB morphology Electrical and mechanical dysynchrony Echo; CRT-P; CRT-D


Source: European Journal of Heart Failure (2008), 933-989 doi:10.1016/j.ejheart.2008.08.005

Chest Radiography: Common Abnormalities in Heart Failure

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Abnormality Causes Clinical Implications

Cardiomegaly Dilated LV, RV, atria; Pericardial effusion Echo/Doppler

Ventricular hypertrophy

Hypertension, aortic stenosis, hypertrophic cardiomyopathy Echo/Doppler

Normal pulmonary findings Pulmonary congestion unlikely

Reconsider diagnosis (if untreated); Serious lung disease unlikely

Pulmonary venous congestion Elevated LV filling pressure Left heart failure confirmed

Interstitial edema Elevated LV filling pressure Left heart failure confirmed

Pleural effusions

Elevated filling pressures; HF likely if bilateral; Pulmonary infection, surgery, or malignant effusion

Consider non-cardiac etiology if abundant; If abundant, consider diagnostic or therapeutic centers

Kerley B lines Increased lymphatic pressures Mitral stenosis or chronic HF

Hyperlucent lung fields Emphysema or pulmonary embolism Spiral CT, spirometry, Echo

Pulmonary infectionPneumonia may be secondary to pulmonary congestion Treat both infection and HF

Pulmonary infiltration Systemic disease Diagnostic work-up



Pro-BNP, BNP and NT-pro-BNPWhen the heart is stressed, it produces a precursor, pro-BNP, which is separated to release the active hormone BNP and an inactive fragment, NT-proBNP

Both BNP and NT-proBNP are produced mainly in the heart’s left ventricle, and released as a natural response to heart failure,hypotension, angina, hypertrophy (when the left ventricle has been “stretched” too much from the accumulation of blood and fluid), or when overworked (i.e. rapid heart rate)

Elevations of BNP are dependent on overall patient condition (including presence and type of co-morbid conditions) and the stage and type of heart failure.

BNP levels should be correlated with other clinical indicators

B-Type Natriuretic Peptide (BNP)


Conditions that Influence BNP Concentrations

Increased BNP:• Age (older)• Sex (female)• Ethnicity (black)• Renal dysfunction• Myocardial infarction/acute coronary

syndromes• Right-sided heart failure (cor

pulmonale, acute pulmonary embolus)• High output failure (cirrhosis, septic

shock)

Decreased BNP:• Obesity

• Early acute heart failure (less than 1 hour)

• Acute mitral regurgitation

• Mitral stenosis (in the absence of right ventricular failure)

• Stable NYHA Class I patients with decreased LV ejection fraction

BNP Values*:• <100 pg/ml = no systolic or diastolic heart failure• 100-200 pg/ml = normal or chronic CHF • 200-400 pg/ml = could be indicative of LV or RV CHF, PE, LVH, ESRD, AMI• >400 pg/ml = overt CHF

*Normal levels and clinical significance of values vary between hospitals and physicians


Echocardiography – Helps Identify the Etiology of Heart Failure


Measurement Abnormality Clinical implicationsLV ejection fraction Reduced (45 - 50%) Systolic dysfunction

LV function; global and focal Akinesis; hypokinesis; dyskinesis Myocardial infarction/ischemia; Cardiomyopathy; myocarditis

End-diastolic diameter Increased (.55 - 60 mm) Volume overload; HF likely

End-systolic diameter Increased (.45 mm) Volume overload; HF likely

Fractional shortening Reduced (25%) Systolic dysfunction

Left ventricular thickness Hypertrophy (.11 - 12 mm) Hypertension; aortic stenosis; hypertrophic cardiomyopathy

Left atrial size Increased (.40 mm) Increased filling pressures; Mitral valve dysfunction; Atrialfibrillation

Valvular structure and function

Valvular stenosis or regurgitation (especially aortic stenosis and mitralinsufficiency)

May be primary cause of HF or complicating factor; Assess gradients and regurgitant fraction; Assess hemodynamicconsequences; Consider surgery

Mitral diastolic flow profile Abnormalities of the early and late diastolic filling patterns

Indicates diastolic dysfunction and suggests mechanism

Tricuspid regurgitation peak velocity

Increased (.3 m/s) Increased right ventricular systolic pressure Suspect pulmonary hypertension

Aortic outflow velocity time integral

Reduced (15 cm) Reduced low stroke volume

Inferior vena cava Dilated Retrograde flow Increased right atrial pressures; Right ventricular dysfunction Hepatic congestion

Pericardium Effusion; hemopericardium; thickening

Consider tamponade; uremia; malignancy; systemic disease; acute or chronic pericarditis; constrictive pericarditis


The Hospitalized Patient – Principles of Treatment

• Stabilize systemic perfusion if necessary

• If fluid overloaded, IV loop diuretics– Initially equal or greater than oral outpatient dose– Later guide by urine output and signs / symptoms

• Increase dose?• Continuous IV diuretic infusion• Add 2nd medication (metolazone, spironolactone)

– While on IV diuretics or changing HF meds, daily basic metabolicpanels

• Monitor I/Os, vital signs, body weight daily

• Check signs and symptoms of perfusion and congestion both supine and standing


The Hospitalized Patient – Principles of Drug Therapy

• Continue home meds as appropriate

• If not on a BB, start while inpatient– Start at a low dose– If not on a BB during admission:

• Start at low dose• Monitor for orthostatic hypotension

• Vasodilators only if– Severely symptomatic volume overload– Inadequate response to diuretics after escalation– No systemic hypotension


The Hospitalized Patient – Other Therapy Options

• Progressive deterioration of renal function BUN >80 mg/dl and Cr>3 mg/dl or hyperkalemia may necessitate discontinuation of ACE inhibitors and spironolactone

• Use of further vasodilators, either oral or intravenous, should be considered

• Intravenous inotropic therapy can improve renal function and allow effective diuresis

• Invasive hemodynamic monitoring– For refractory symptoms and signs

• Ultrafiltration or hemodialysis may be necessary


Initial Management of Acute Heart Failure

Target Therapeutic example

Mechanism of action Side effects

Alleviate congestion

IV furosemide Water and sodium excretion

Electrolyte abnormalities

Reduce elevated LV filling pressures

IV nitrates Direct relaxation of vascular smooth muscle cells through various mechanisms

Hypotension, decreased coronary perfusion pressure


Target Therapeutic example

Mechanism of action Side-effects

Poor cardiac function

Inotropes Activate Cyclic adenosinemonophosphate (cAMP) or calcium sensitization, resulting in improved contractility andvasodilation (with increased sympathetic tone)

Hypotension, arrhythmias, myocardial damage, association with increased morbid events

Tachycardiaand increased systemic blood pressure (i.e. in cases of excessive sympathetic tone)

Beta-blockers: IV esmolol may be used when HF is related to AF with RVR and/or severe hypertension

Blockade of beta-1 and beta-2 receptors

Bradycardia,hypotension, negative inotropy; however given short half-lifeesmolol, these side-effects should be short-lived

Initial Management of Acute Heart Failure (cont.)


Use of Diuretics

• Helpful in relieving congestion and decreasing volume overload: consider loop diuretics as first choice

• Multiple divided doses versus continuous infusion

• High-dose versus low-dose loop diuretics

• Consider combination of diuretics.

• Precipitation of metabolic abnormalities

• May predispose to arrhythmias

• Worsening of renal function

• Lower the dose as tolerated once euvolemic state is achieved.

Appropriate Adverse Effects


• Diuretics are useful in relieving the symptoms of congestion andcorrecting the volume overload, but excessive diuresis can cause metabolic abnormalities and adversely effect the neurohormonalbalance.

• Vasodilator therapy should be aggressively pursued for controlling thehemodynamic abnormalities and relief of symptoms in acutedecompensated heart failure.

• Beta blockers should be continued through hospitalization when admitted with ADHF unless contraindicated. Beta blockers should be part of discharge medication regimen unless contraindicated.

• ACEi/ARB should be continued through hospitalization in spite of modest deterioration in renal function and should be optimized prior to discharge, unless contraindicated.

• Aldosterone antagonists should be considered for patients in Class III and Class IV CHF, unless contraindicated.

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Additional Medication Considerations



Indications for Invasive TherapyImplantable Cardioverter Defibrillator

• Nonischemic cardiomyopathy or ischemic heart disease at least 40 days post MI with ejection fraction of <35% with NYHA Class II or III symptoms on maximum chronic optimal medical therapy and reasonable expectation of survival of more than 1 year with goodfunctional status.

Indications for Cardiac Resynchronization Therapy

• Sinus rhythm

• QRS duration >0.12 msec

• LVEF <35%

• Typically NYHA functional Class II or III, but any patient regardless of NHYA class can be considered (new addition to ACC in 2009)

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Major Scenarios for Consideration ofImplantable Cardiac Defibrillators in HF

Scenario 1• Current/prior symptoms of HF• Reduced LVEF with history of cardiac arrest, ventricular

fibrillation, or hemodynamically destablizing ventriculartachycardia

Scenario 2• Nonischemic Cardiomyopathy or Ischemic disease, 40

days post myocardial infarction and a LVEF < 35%• NYHA Class II or III on optimal therapy• Expected survival > 1yr

Scenario 3• LVEF < 35%• Sinus rhythm or Atrial fibrillation• NYHA Class III or Class IV on optimal therapy• Cardiac dyssynchrony (QRS >= 0.12 seconds)


Secondary prevention to

prolong survival

Primary prevention of sudden cardiac

death

Consider for that are severely symptomatic –also consider AICD with Resynchronization Therapy

Heart Failure Documentation Improvement Key Concepts

For acute care, documentation should indicate severity of the patients illness or condition, key terms that indicate severity and / or specify the patient's condition:

• Document the etiology of the cardiomyopathy – such as hypertensive heart disease, ischemic heart disease, valvular and which valve(s), viral, alcoholic, etc.). This documentation reflects a higher level of evaluation.

• Document the known results of cardiac function studies and state whether they reflect failure due to left ventricular systolic dysfunction, left ventricular diastolic function or both.

• Clarify the patient’s heart failure status (due to chronic left ventricular systolic or diastolic dysfunction) and whether the current episode reflects acutedecompensation.

• Document whether the patient had an acute MI within eight weeks of this episode and whether the acute MI was the cause of this episode ofdecompensation.

• Name/document the relationship if this is a CKD patient and volume overload or non-cardiac pulmonary edema led to the decompensation.


TRANSITIONS TO AMBULATORYHeart Failure


Heart Failure Care Transitions Hospital to Ambulatory

Goals: Coordination with Primary Care

• Help patients understand the importance of avoiding readmission by reinforcing the following:– Take medication as prescribed (understanding purpose of meds)– Keep appointments with your doctors (primary care and other providers)– Keep track of daily weights and nutrition (especially salt and fluids restriction)

and bring health records to doctor visits– Get daily physical activity– Know the warning signs and what do to for increasing symptoms of HF– Maintain a healthy lifestyle to improve overall well being

• Primary care providers should understand readmission risk scores and how their patients would benefit from remote monitoring


Heart Failure Care TransitionsCauses of Hospital Readmission for CHF

HFSA Research 2000


Heart Failure Care TransitionsRemote Monitoring and Readmission Risk

Remote Monitoring (Tele-health) – Studies have shown that monitoring HF patients through telephone or other device monitoring can reduce HF Readmissions

Readmission Risk – Several tools are publically available and include LACE; Modified LACE; Yale New Haven Readmission Risk Tool

Risk Assessment can help clinicians understand a HF patient’s individual needs for management across care settings (Transitions or Health Coach; Home Care; Remote Monitoring i.e. Tele-monitoring; or Palliative Care)


• Initiate Palliative Care at the diagnosis

• Intended for people with serious illnesses

• Focus is on providing patients with relief from their symptoms and the stress of a having a serious illness and improving quality of life — no matter the diagnosis

• Appropriate at any age and at any stage of an illness, and it can be provided along with treatments that are meant to cure.

Heart Failure Care Transitions Palliative Care Integrative Model


Newer

Figure 1. Palliative Care Integrative Model Figure 2. Disease-Directed Palliative Care Model


Conclusions

• Manage HF better by using evidence-based guidelines more consistently– Early recognition of HF and prompt action in outpatient and inpatient

settings– Careful, anticipatory, collaborative care especially at transitions

ambulatory ↔ acute care– Patient and caregiver education

• Prevent readmissions– Ambulatory monitoring– Discharge planning– Invasive, restorative or palliative care

• Learn from best practices– From peers– From Trinity organizations

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Appendix


• ACC Guideline Drug Tables pgs 62 – 64

• ACC Stages and Treatments Options pgs 65 – 66

• Clinical Profiles of Acute Heart Failure pg 67

• Heart Failure ICD-9 Codes pg 68

• Ventricular Remodeling Definition pg 69

Drug Stage A Stage B Stage C

Ace Inhibitors

Benazepril (Lotensin) H

Capropril (Capoten) H, DN Post MI HF

Enalapril (Vasotec, Renitec) H, DN Asymptomatic LVSD HF

Fosinopril (Monopril) H HF

Lisinopril (Prinivil, Zestril) H, DN Post MI HF

Moexipril (Univasc) H

Perindopril (Aceon) H, CV Risk

Quinapril (Accupril) H HF

Ramipril (Altace) H, CV Risk Post MI Post MI

Trandolspril (Mavek) H Post MI Post MI

Angiotensin Receptor Blockers

Candesartan (Atacand) H HF

Eprosartan (Teveten) H

Irbesartan (Avapro) H, DN

Losatan (Cozaar) H, DN CV Risk

Olmesartan (Benicar) H

Telmisartan (Micardis) H

Valsartan (Diovan) H, DN Post MI Post MI, HF

Cardiovascular Medications Useful for Treatment of Various Stages of Heart Failure

CV Risk –Reduction in future cardio-vascular risk

DN –Diabetic Nephropathy

H – Hypertension

HF - Heart Failure

LVSD – Left ventricular systolic dysfunction

2005 ACC / AHA Guidelines for Diagnosis and Management of Heart Failure in Adults


Drug Stage A Stage B Stage C

Aldosterone Blockers

Eplerenone (Inspra) H Post MI Post MI

Spironolactone (Aldactone) H HF

Beta-Blockers

Acebutolol (Sectral) H

Atenolol (Senormin, Tenormin) H Post MI

Betaxolol (Kerlone) H

Bisoprolol (Zebeta) H HF

Carteolol (Cartrol) H

Carvedilol (Coreg) H Post MI HF, Post MI

Labetalol (Trandate, Normodyne) H

Metoprolol succinate (Toprol XL) H HF

Metroprolol tartrate (Lopressor) H Post MI

Nadolol (Cargard) H

Penbutolol (Levatol) H

Pindolol (Visken) H

Propranolol (Inderal) H Post MI

Timolol (Betimol, Istalol) Post MI

Digoxin HF

CV Risk –Reduction in future cardio-vascular risk

DN –Diabetic Nephropathy

H – Hypertension

HF - Heart Failure

LVSD – Left ventricular systolic dysfunction

Cardiovascular Medications Useful for Treatment of Various Stages of Heart Failure

2005 ACC / AHA Guidelines for Diagnosis and Management of Heart Failure in Adults


Drug Initial Daily Dose (s) Max Total Daily Dose Duration of ActionsLoop Diuretics

Bumetanide (Bumex) 0.5 to 1.0 mg once or twice 10 mg 4 to 6 hours

Furosemide (Lasix) 20 to 40 mg once or twice 600 mg 6 to 8 hours

Torsemide (Demadex) 10 to 20 mg once 200mg 12 to 16 hours

Thiazide Diuretics

Chlorothiazide (Chlotride, Diuril) 250 to 500 mg once or twice 1000 mg 6 to 12 hours

Chlorthalidones (Thalitone) 12.5 to 25 mg once 100 mg 24 to 72 hours

Hydrochlorothiazide (HydroDIURIL) 25 mg once or twice 200 mg 6 to 12 hours

Indapamide (Lozol) 2.5 mg once 5 mg 36 hours

Metolazone (Mykrox, Zaroxolyn) 2.5 mg once 20 mg 12 to 24 hours

Potassium-Sparing Diuretics

Amiloride (Midamor) 5 mg 20 mg 24 hours

Spironolactone (Aldactone) 12.5 to 25 mg once 50 mg 2 to 3 days

Triamterene (Dyrenium) 50 to 75 mg twice 200 mg 7 to 9 hours

Sequential Nephron Blockade

Metolazone (Mykrox, Zaroxolyn) 2.5 to 10 mg once plus loop diuretic

Hydrochlorothiazide (HydroDIURIL) 25 to 100 mg once or twice plus loop diuretic

Chlorothiazide (Chlotride, Diuril) (IV) 500 to 1000 mg once plus loop diuretic

Oral Diuretics Recommended for Use in the Treatment of Fluid Retention in Chronic HF

2005 ACC / AHA Guidelines for Diagnosis and Management of Heart Failure in Adults642012 Trinity Health - Novi, Michigan - INTERNAL

Jessup M. and Brozena S. N Engl J Med 2003;348:2007-2018


ACC/AHA Stages and Treatment for Heart Failure


Clinical Profiles of Acute Heart Failure

(Dickstein et al)

67

Hypertensive AHF

AcutelyDecompensated

Chronic HFPulmonaryEdema

ACS and HF

CardiogenicShock

Right HF


Heart Failure ICD-9 CM Codes


ICD-CM-9 Codes for Heart Failure428 Heart failure – heart failure due to hypertension list first a hypertension code, using the following (402.0-402.9, with fifth-digit 1 or 404.0-404.9 with fifth-digit 1 or 3) as appropriate; Excludes: rheumatic (398.91)428.0 Congestive heart failure, unspecified; Congestive heart disease; Right heart failure (secondary to left heart failure)Excludes: fluid overload NOS (276.6)

428.2xSystolic heart failure (see specific 5th

digit below)

428.3x Diastolic heart failure (see specific 5th digit below)

428.4x Combined Systolic/Diastolic heart failure (see specific 5th digit below)

428.1 Left heart failure - Acute edema of lung with heart disease NOS or heart failure; Acute pulmonary edema with heart disease NOS or heart failure; Cardiac asthma; Left ventricular failure

428.20 Unspecified

428.30 Unspecified

428.40 Unspecified

428.21 Acute 428.31 Acute 428.41 Acute428.9 Heart failure, unspecifiedCardiac failure NOS; Heart failure NOS; Myocardial failure NOS; Weak heart 428.22

Chronic428.32 Chronic 428.42 Chronic

428.23 Acute on chronic




Table 1: Ventricular remodeling: definition and consequences Definition: A cascade of changes in genome expression, cells, molecules, and interstitiumthat alters the size, shape, and function of the left ventricle after injury. Alterations in heart size and shape (volume) that are not associated with preload-mediated increase in myocytelength.

Hallmarks leading to change in shape of left ventricle from a V to a U include a Combination of:

• Dilatation (myocyte lengthening and cell slippage)• Cell loss/death (apoptosis) • Interstitial fibrosis• Heart failure after myocardial infarction: formation of a discrete collagen scar• Nonischemic heart failure: isolated fibrosis• Hypertrophy (see Figure 1b and c) Initially concentric (thickening of myocytes); Then

becomes eccentric (thinning of the left ventricular walls)

Consequences:• High pressure (wall stress) in the ventricle during systole and diastole heightens

myocardial oxygen consumption, a situation that promotes further hypertrophy andactivates neurohormonal systems

• Reduction in ejection fraction; Reduced ventricular performance Morbidity and mortality

Source: CRITICALCARENURSE Vol 24, No. 6, DECEMBER 2004 , pg 18

Ventricular Remodeling - Definition

References1. 2005 / 2009 ACC / AHA Guidelines For Diagnosis And Management Of Heart Failure In Adults

2. Wier LM, Levit K, Stranges E, et al. HCUP Facts and Figures: statistics on hospital-based care in the United States, 2008: exhibit 2.3, most frequent principal diagnoses by age. Agency for Healthcare Research and Quality. http://www.hcup-us.ahrq.gov/reports.jsp.

3. Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009;360(14):1418-1428.

4. Lloyd-Jones D, Adams RJ, Brown TM, Et Al. Heart Disease And Stroke Statistics—2010 Update. A Report From The American Heart Association Statistics Committee And Stroke Statistics Subcommittee . Circulation. 2010;121:e1-e170.

5. Heart Failure Society Of America 2010 Guideline Executive Summary. Journal Of Cardiac Failure 2010;16:476-506.

6. Dickstein et al. European Journal Of Heart Failure (2008), 933-989 Doi:10.1016/J.Ejheart.2008.08.005

7. Eric D. Adler, MD; Judith Z. Goldfinger, MD; Jill Kalman, MD; Michelle E. Park, BA; Diane E. Meier, MD, Palliative Care In The Treatment Of Advanced Heart Failure Http://Circ.Ahajournals.Org/Content/120/25/2597

8. CRITICALCARENURSE Vol 24, No. 6, December 2004 , Pg 18

9. Jessup M. And Brozena S. N Engl J Med 2003;348:2007-2018

10. HFSA Research 2000


http://www.hcup-us.ahrq.gov/reports.jsp




http://circ.ahajournals.org/content/120/25/2597

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Post Test:Questions and Answers


1. True or False: Heart Failure is diagnosed on the basis of diagnostic testsFalse: HF is diagnosed on the presence of characteristic signs and symptoms and not on the basis of any diagnostic

tests2. ______ heart failure is characterized by: an inability of heart muscle to contract vigorously;

results in inadequate amount of blood and oxygen to body; and is evidenced by Ejection Fraction usually less than 40%

a. Systolic Heart Failureb. Diastolic Heart Failurec. Both Systolic and Diastolic Heart Failured. Neither Systolic or Diastolic heart Failure

3. What stage and class is a person in end stage Heart Failure?a. Stage A/Class Ib. Stage D/Class IVc. Stage B/Class IId. Stage C/Class III

4. True or False: When treating older patients with ARBs, one should: “start low and go slow”True

5. These are goals for what setting of Heart Failure treatment: Establish the diagnosis; Review signs and symptoms; Identify adequacy of systemic perfusion and volume status

a. Ambulatory goalsb. Transitional goalsc. Emergency and Inpatient goalsd. These are not goals for any setting of Heart Failure treatment

72

Post Test Cont.:Questions and Answers


6. Which of the tests listed below if not a key test for hospital management of Heat Failure:a. ECGb. Chest radiographyc. ProBNP or NT-proBNPd. These are all key tests

7. True or False: Excessive diuresis will not cause metabolic abnormalities or adversely effect the neurohormonal balance

False: Diuretics are useful in relieving the symptoms of congestion and correcting the volume overload, but excessivediuresis can cause metabolic abnormalities and adversely effect the neurohormonal balance

8. What is Acute Decompensated Heart Failure Presentation?a. Volume overloadb. Profound depression of cardiac outputc. Combination of A and Bd. All of the above

9. True or False: Patient and caregiver education will assist in the patient’s Heart Failure management

True

10. What of the below options are potential causes for readmission:a. Failure to see careb. Prescription non-adherence c. Diet non-adherence d. All of the above

management of acute decompensated heart failure of hf_c… · 2012 trinity health - novi, michigan...

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